US Pharm. 2008;33(9):3.

When the great English poet Alexander Pope wrote, "To err is human, to forgive divine," I don't think he was referring to the legal sharks that feed off the errors made by health care professionals. While some minor moral errors of judgment may be forgiven, many victims of serious medical errors often suffer terrible consequences at the hands of negligent health care professionals. While most health care professionals have only the best interests of their patients at heart, there is no escaping the fact that medical errors, unfortunately, do occur. The fact is, unless they're psychotic, there is not a health care professional in practice today who goes out of his or her way to make an error. Sadly, as good a pharmacist you perceive yourself to be, your working environment and other external forces play heavily into whether or not you will make an error at some time during your career.

I would venture to say that there are thousands--if not tens of thousands--of errors made in pharmacies throughout the country in the course of a year. Some relatively trivial errors are caught before the patient ever picks up the prescription and others are relatively minor and easily rectified, but still others can result in dire consequences for the patient. It is too often the dire consequences that get all the media attention. Take, for example, the overdose of heparin given to the newborn twins of actor Dennis Quaid and his wife Kimberly some months ago. In that event, Los Angeles's Cedars-Sinai Medical Center was fined $25,000 by the California Department of Public Health. The Quaids believe that the manufacturer was at fault for not properly differentiating the adult-strength heparin given to their babies from the pediatric strength of the same drug. Thankfully, the twins survived the terrible ordeal, but the incident served as an example and raised awareness of the fact that something needs to be done to ensure the safety of medications dispensed by pharmacists.

Even more disconcerting was a recent news report concerning drug errors that are only indirectly related to pharmacists. Researchers at the University of Pennsylvania reported that most fatal medication errors occur in the home, not in the hospital. Deaths from these errors have increased six-fold over the past two decades. The authors said that their research shows the reason for the dramatic rise in deaths due to at-home drug errors is the personal mismanagement of prescription drug use. When you factor in the mixing of legal medications with street drugs or alcohol, the numbers of adverse events and deaths are off the charts.

The data were extracted from nearly 50 million death certificates in the U.S. What is clear from this study is that the number of deaths related to pharmacy errors is minimal compared with what happens in the privacy of one's home. Pharmacists can and should fight this dramatic rise in at-home medication errors by communicating regularly with their patients about the drugs they are taking. Frequent compliance checks will often enable pharmacists to head off any serious consequences from the drugs they dispense once the patient leaves the pharmacy. Unlike Pope's lofty quotation, making errors may be human, but doing nothing to prevent them is certainly not divine when it comes to prescription drugs.

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